UC Berkeley UC Berkeley Electronic Theses and Dissertations Title Patterns of Care, Status Differentiation, and the Reproduction of Inequality in Hospital Nursing Permalink https://escholarship.org/uc/item/47t4v9qk Author Kaiser, John William Publication Date 2015 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California Patterns of Care, Status Differentiation, and the Reproduction of Inequality in Hospital Nursing by John William Kaiser A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Sociology in the Graduate Division of the University of California, Berkeley Committee in Charge: Raka Ray, Chair Barrie Thorne Evelyn Nakano Glenn Summer, 2015 Abstract Patterns of Care, Status Differentiation, and the Reproduction of Inequality in Hospital Nursing by John William Kaiser Doctor of Philosophy in Sociology University of California, Berkeley Professor Raka Ray, Chair Feminist scholars have established care work as a key site for intersecting systems of power. The naturalization of feminized caring legitimates the institutionalized coercion and exploitation of care work, inflecting a matrix of inequalities built up around these relations of caring labor. However, there has been little systematic analysis of the mechanisms of social reproduction through caring labor in a medical setting. This project, based on three years of IRB-approved ethnography of RNs and CNAs at work in a California hospital, addresses this gap. It analyzes the social processes in the social construction of care, illustrating how RNs created and used culture to mitigate coercion, exploitation, and subordination. Specifically, they used semiotic codes—and their respective sets of daily practices—to define what counted as “care” in particular contexts. They also delegated tasks linked with servitude to CNAs through rituals of subordination. These processes enabled RNs to assert professional power, but they also linked status differentiation to empathy/disempathy, facilitated affective structures and subjectivities of disempathy, and reproduced racialized relations of domination between themselves and the CNAs. Thus, mechanisms of empathy/disempathy reproduced inequality. This analysis identifies the limitations of professional nursing power based on the ideological dichotomization of emotional and technical dimensions of medical work and highlights how this ideology—and the structure of feelings that animate it—obscures the actual role of empathy as medical work. This research leads to the formulation of a general theory of empathy/disempathy as a mechanism that contributes to inequality. The argument is that structures of domination, coercion, and exploitation devalue and constrain care throughout the social formation. Institutions that order these power relations are organized through affective structures—and their corresponding ideologies and subjectivities—that link status differentiation to empathy/disempathy. Mechanisms of empathy/disempathy rearticulate the ideological interpellation of subjects by shaping “subject-centric” perceptions of power and determining the processes through which people produce and use culture to rationalize it. On one hand, hegemonic structures of feeling constrain capacities to care and facilitate subjectivities of disempathy . These subjectivities refract experiences of agency through disempathy, power, and status. On the other hand, another category of subjectivity, which I call double-agency, constructs experiences of agency through capacities for empathy— and estrangement from those very capacities. Consequently, processes of empathy/disempathy function as a mechanism in the social reproduction of inequality. 1 This dissertation is dedicated to the hospital workers whose collaborative efforts helped Willy through severe illness by “raising my spirits, and keeping me comfortable and alive,” as he put it. i Contents Preface Acknowledgements Introduction 1 The Basic Stuff of Having Heart: South Heart’s Paradoxical Culture of Care 2 An Atmosphere of Normalcy: Empathy in Care Delivery 3 Don’t Baby Them!: Disciplinary Practices of Care Delivery 4 Servitude and the Matrix of “Double Agency” Subjectivities 5 Professionalizing Borderwork 6 Conclusion Bibliography ii Preface This project was born at the side of my father’s bed in a hospital where I observed nurses at work for the first time. Willy and I experienced firsthand the power of caring in a medical setting, the constraints on care, and the non-duality of emotional and technical dimensions of medical work. Now years later as he courageously lies in the ICU once again, the full-fruition of this project feels like the silver-lining of his illness trajectory. Berkeley, August 9 th , 2015 iii Acknowledgements Barrie Thorne made this research possible with her offering to Chair my dissertation. She guided the process, mentoring me with time, encouragement, extensive knowledge, and a mindful approach to training in which she cleverly honed in on the precise areas where I needed to grow. Our many stimulating discussions, in which she used a modified-Socratic method for mental calisthenics, helped grow ideas in the garden of my mind. She guided me through the process of data analysis, creative-yet-grounded generation of ideas, and making connections between seemingly unrelated phenomena. It was there, in those many visits to her office, that this research blossomed as a collaborative flower of both our gardens. She also taught me the tacit and explicit knowledge of caring as a scholarly activity, which guided my research as well.1 Raka Ray generously took on the responsibilities of Chair when health problems prevented Barrie from doing it any longer. This dissertation would not have been possible without her skillful advising, patience, and feedback. Her work on cultures of servitude was invaluable in helping me make sense of the contours around categories of devalued and delegated tasks. Evelyn Nakano Glenn also contributed her time, support, and intellect to support as Outside Committee Member. Her work on the intersecting systems of power and caring labor made this analysis possible. Ann Swidler trained me in sociology of culture and provided support as Chair of my Orals Committee. She also advised me on the dissertation. Her work in the sociology of culture provided a framework for my original research design and continued to inform my analysis. It also provided countless hours of entertainment as I contemplated the enigma of cultural logic. Dawne Moon advised my master’s thesis and trained me in the techniques of participant observation and analysis of ethnographic data. Our many stimulating conversations in her Barrows office shaped the development of both my research agenda and my sociological imagination. Arlie Hochschild also contributed to my growth as a scholar. In particular, her perceptive feedback helped me address one of my challenges; as she put it, I generated creative lines of analysis, but had trouble staying focused and following through with them. When I contemplated taking an extended leave of absence to help my parents, she encouraged me to “keep the ball rolling.” I am grateful for her wise advice. Dylan Riley trained me in social theory. In so doing, he nurturing my interest in theories of consciousness and human freedom. Every member of the Sociology Department’s staff contributed to this project in one way or another. Elsa Tranter, Anne Meyers, and Carolyn Clark, in particular, provided crucial support. Their skillful advising guided me through the logistics of the program. Their practices of empathy produced a dialogical knowledge of my personal circumstances, which augmented their application of their other specialized knowledge. My undergraduate mentors at Occidental College—Monique Taylor, Jan Lin, Dolores Trevizo, Elizabeth Chin, and Peter Drier—helped me cultivate my scholarly subjectivity in its formative years. The folks at the Care Work Network provided the support and stimulation of a community of scholars. I have very fond memories of the conferences I 1 Michael Polanyi (1966) describes tacit knowledge as conducive to learning through observation, imitation, and practice. iv attended. My friends and family, did everything they could—which was more than a lot— to support me on this long, strange trip. 2 Finally, the nurses with whom I worked made this research a collective intellectual process. I can only hope that my analysis resonates with their lived experiences. 2 I am refraining from naming names for fear of forgetting somebody. v Introduction If nurse means comforter... who will be called “nurse” when the nurse’s tasks are reshuffled? Will it be the teacher and supervisor? The bedside comforter? Or will it be those who give more humble services? -Everett Hughes (1951) Delegating care to people of lower status further devalues the work and the people doing it. -Evelyn Nakano Glenn (2000) In 1951 Everett Hughes predicted that the professionalization of nursing would involve the “reshuffling” of tasks related to care down to workers of lower status. His idea was based on an understanding that people professionalize their occupations by claiming tasks of higher prestige while distancing themselves from less-desirable tasks and “dirty work.” 3 Thus, Registered Nurses (RNs) would reshuffle their care work—which he described as “comforting”—onto others as RNs embraced more technical medical tasks. He reasoned that these